The Determinants of Private Medical Insurance Prevalence in England

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1 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Derek R. King, Elis Mossilos LSE Helth nd Socil Cre, London School of Economics nd Politicl Science LSE Helth nd Socil Cre Discussion Pper Numer 3 First pulished in My 2002 y: LSE Helth nd Socil Cre The London School of Economics nd Politicl Science Houghton Street London WC2A 2AE 2002 Derek R. King nd Elis Mossilos All rights reserved. No prt of this pper my e reprinted or reproduced or utilised in ny form or y ny electronic, mechnicl, or other mens, now known or herefter invented, including photocopying nd recording, or in ny informtion storge or retrievl system, without permission in writing from the pulishers. British Lirry Ctloguing in Puliction Dt A ctlogue record for this puliction is ville from the British Lirry. ISBN [ ]

2 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Acknowledgements The British Household Pnel Survey is crried out y the Institute for Socil Reserch nd theuniversityofessex.thedtweremdevilleytheessexdtarchive.dton NHS witing times were provided y the NHS Witing Times Tem. Dt on physicin contcts were provided y the Sttistics Division of the Deprtment of Helth - Workforce Sttistics Brnch. We re lso grteful for the vlule comments provided y Mr José Fernndez, Professor Ry Roinson nd Dr Jon Cost-I-Font. All remining errors re strictly those of the uthors. Astrct At the end of the yer 2000, 6.88 million people in the UK (pproximtely.5% of the popultion) were covered y Privte Medicl Insurnce (PMI). The im of this pper is to exmine possile determinnts of the prevlence of PMI in Englnd y using dt from the British Household Pnel Survey (BHPS) , the Deprtment of Helth nd Ling's Helthcre Mrket Review The BHPS is suitle for nlyses of the determinnts of PMI prevlence in Englnd s individul respondents re followed over time, nd thus chnges tht tke plce over time re incorported in the nlysis of ssocitions etween potentil determinnts nd PMI coverge. The nlysis lso incorportes NHS witing times dt nd dt on potentil supply-side fctors. The results support the conclusion tht income, ge nd politicl ffilition re key determinnts of PMI prevlence. These vriles repetedly exhiit sttisticl significnce in nlyses of the determinnts of PMI prevlence. The results lso suggest tht individuls reflect on prior informtion with regrds to witing times in deciding whether or not to purchse PMI cover. Also, the withdrwl of the tx susidy to PMI suscriers over 60 yers of ge did not impct on their rte of withdrwl from PMI coverge reltive to the rte mongst ll PMI suscriers, ut my hve discourged potentil new suscriers. Aout the uthors Derek King is reserch officer t LSE Helth nd Socil Cre t the London School of Economics nd Politicl Science. Emil: Telephone: 44 (0) ; Fx 44 (0) Elis Mossilos is Co-director of LSE Helth nd Socil Cre nd Reder in Europen Helth Policy t the London School of Economics nd Politicl Science Correspondence should e ddressed to: Derek King, LSE Helth nd Socil Cre, London School of Economics nd Politicl Science, Houghton Street, London WC2A 2AE, United Kingdom.

3 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Contents Contents...2 Introduction...3 Trends in Privte Medicl Insurnce prevlence...3 Modelling the decision to purchse privte medicl insurnce...6 Evidence from empiricl studies...9 Developing hypotheses nd reserch questions...2 Methods...4 Results...8 Discussion...27 Conclusion...29 Appendix A...3 Appendix B...32 References

4 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Introduction The UK Ntionl Helth Service (NHS) Act of 946 ws sed on the stte hving collective responsiility for the provision of comprehensive helth cre, which ws to e ville, without cost, to the entire popultion. Despite this, privtely supplied medicl tretments hve ecome strong feture of the provision of helth services. It hs een estimted tht y 986, the privte sector ws crrying out 6% of ll elective surgery undertken on UK residents. In , 4.% of elective hospitl cre in Englnd nd Wles ws provided in privte hospitls 2 nd 25 privte medicl insurers were offering coverge in the United Kingdom. As of the lte 990s, there were pproximtely 230 independent medicl hospitls in the United Kingdom. 3 The mjority of independent cre is purchsed through privte medicl insurnce. In 997/98, 8% of ptients in Englnd nd Wles pid for cre in n independent hospitl through privte medicl insurnce (PMI). 4 At the end of the yer 2000, 6.88 million people in the UK (pproximtely.5% of the popultion) were covered y PMI nd the vlue of the PMI mrket ws estimted t 2.45 illion, 5 4.5% of the estimted yer 2000/200 udget for the NHS of 54.2 illion. 6 The im of this pper is to exmine possile determinnts of the prevlence of privte medicl insurnce in Englnd. Tht is, to shed light on the fctors which encourge individuls to purchse privte helth insurnce, despite the vilility of cre from the NHS. Using dt from the British Household Pnel Survey (BHPS) , the Deprtment of Helth nd Ling's Helthcre Mrket Review , potentil determinnts of the uptke of PMI re exmined. The BHPS includes extensive dt relting to PMI nd severl fctors thought to impct upon the decision to purchse PMI. The pnel nture of the survey llows households to e followed over the yers for which dt on PMI suscription re ville. The BHPS is rich source of dt eing used for the first time to dd evidence to the determinnts of PMI prevlence. Our nlysis lso incorportes dt on inptient nd outptient witing times estimted t the helth uthority level (provided y the NHS Witing Times Tem), s well s dt on the vilility of privte cute cre eds, t the regionl level (tken from Ling's Helthcre Mrket Review ) nd estimtes of the regionl distriution of physicins working in the privte helth cre sector (provided y the Work Force Sttistics Brnch of the Deprtment of Helth). The results dd new evidence to other empiricl nlyses of wht fctors determine the size of the privte medicl insurnce mrket in Englnd. Trends in Privte Medicl Insurnce prevlence The prevlence of PMI grew drmticlly etween 985 nd 990, with the numer of suscriers incresing y lmost 30% during this period. 7 TheprevlencerteofPMItthe end of the yer 2000 ws.5%. 5 Since 988, Ling nd Buisson, in their nnul review of the PMI mrket, hve differentited etween individully purchsed PMI nd PMI purchsed y employers on ehlf of their employees. The numer of suscriers covered through employer pid pln hs incresed y pproximtely 23% since 990, while during the sme period, the numer of suscriers who were either pying individully or s employees (s 3

5 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd prtil pyment of compny pln) declined y out 6%. 5 At the end of 2000, 66.5% of PMI suscriers were in plns fully pid for y their employer (see Figure ). 5 Between 980 nd 989, period tht prtly coincides with the increse in PMI prevlence, the supply of privte fcilities incresed t similr rte. Mny of these new fcilities were locted in the south est of Englnd. During this period, the numer of privte cute cre hospitls in the UK incresed y over 36% (from 50 to 205) nd the numer of privte cute cre eds y over 56% (from 6,67 to 0,433). 8 The totl numer of cute cre eds in UK privte cute cre hospitls (0,433) in 989, ws 8.5% of the numer in Englnd within the NHS (23,450 for ). 9 As of 999 there were 0,35 independent cute medicl/surgicl hospitl eds in the UK. 0 This is 9.7% of the numer of NHS cute cre eds in Englnd t the time (07,28 in ). 0 The Thtcher nd Mjor Conservtive governments, in power from 979 to 997, encourged the growth of privte hospitls. Rther thn pprove privte hospitls on the sis of locl helth cre needs, they mde profitility the min criterion for development. They lso mde it more ttrctive for NHS consultnts to undertke privte prctice, nd introduced tx incentives for oth employer pid nd individul privte medicl insurnce plns. Premiums pid y employers on ehlf of their employees were mde tx deductile, s were premiums pid y low-pid workers for individul plns. Employers lso did not py employers' Ntionl Insurnce contriutions on PMI provided to employees s enefit-in-kind. Additionlly, in 990, tx relief t the sic rte ws provided to holders of individul privte medicl insurnce over ge 60. Figure : Percentge of UK Popultion Covered y PMI Percent All PMI * * Compny pid Indiv./Employee pid.5% 8.0% 3.5% * Decreses due to re-estimtion of multiplier which converts suscriers to persons covered. * * Source: Ling nd Buisson, UK Privte Medicl Insurnce Mrcket Sector Report 2000 &

6 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd In August 997, the Lour government ended tx relief for PMI premiums pid y those over the ge of Other udgetry mesures introduced y the Lour government likely to hve n effect on demnd for PMI re rise in Insurnce Premium Tx to 5% from 4% (introduced in Octoer 994 t n initil rte of 2.5% 3 ) nd the extension of employer pid ntionl insurnce contriutions to cover PMI enefits in kind from April These chnges were likely to e ideologicl nd the result of evidence suggesting tht incentives intended to increse PMI prevlence were expensive, nd lrgely unsuccessful in stimulting demnd. 4 In prticulr, retes tend not to e self-finncing lrgely ecuse they enefit current PMI suscriers nd do not encourge sufficient numer of new suscriers from whom the NHS would potentilly relise svings. 4 The reduction in individul PMI coverge witnessed etween 996 nd 2000 my e due to premium levels pproching the point eyond which consumers elect to discontinue cover. Individul PMI premiums re estimted to hve incresed y over 5% in the clendr yer round 5 times the rte of infltion during the sme period. 5 In 2000, the verge nnul premium for n individul (including employee pid PMI) medicl insurnce policy ws pproximtely 987 per suscrier nd 592 per person covered (individul suscriers my py for coverge which extends to one or more dependents). 5 Another fctor my e the elimintion of tx relief for those over ge 60. This resulted in 29.9% increse in premiums for individul suscriers over ge 60 nd hs een ttriuted with reducing PMI prevlence in the over 60's from 9.2% to 8.8%. 4 With respect to the trend towrds compny pid PMI, this employment enefit is most prevlent in professionl nd mngeril jos nd the service industry. Dt from the 987 Generl Household Survey ws one of the first to show this trend. Tht dt indicted tht 34% of people ged in professionl occuptions were covered y PMI, compred with only 3% of skilled mnul workers. 6 This cn lso explin some of the regionl vrition in PMI uptke tht hs een oserved in some studies. 7 Clnn et l noted from their nlysis in 99 tht 20% of the popultion in the outer London Metropolitn re were covered ut only 4% coverge existed in the north of Englnd. Current trends lso suggest tht compny pid PMI plns re displcing some of the demnd for individul policies. Two fctors thought to impct on the prevlence of compny pid plns re the underlying strength of corporte economic performnce nd the chnging ttitude of employers towrds purchsing PMI for their employees. 3 If these conditions continue to exist, it is likely tht demnd for individully purchsed PMI will continue to decline s more people will receive PMI through their employer nd will not then seek individul PMI coverge. It would pper tht the shift towrds compny pid plns in the PMI mrket is lso prtly the result of shift in emphsis y the insurers themselves. Strtegic price discounting nd incresed concentrtion of mrketing re lso descried s key fctors for these increses. 3 The reson for this shift in emphsis my e tht insurers perceive greter cpcity for premium growth in this sector of the mrket. Dt from the pst three yers suggest tht price increses in premiums re less likely to result in decresed demnd in the compny pid sector s compred to the individul sector. Estimtes of elsticity of demnd for compny pid plns in the four yers 997, 998, 999 nd 2000 were.40, 3.00, 0.56 nd.42 respectively, while for individul plns the corresponding elsticities were -0.49, -0.9,

7 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd nd However, the estimtes for the compny pid plns re likely result of chnges in fctors other thn price nd demnd (eg. corporte income), nd thus not true indictors of price elsticity. Also insurers my prefer to focus on employment-sed group insurnce s individuls in this mrket tend to e younger nd helthier s compred to individul suscriers, 8 nd therefore less likely to mke clims. It is lso worth noting tht while the demnd for privte medicl insurnce in the UK is tken to represent demnd for service ville free t the point of use for ll memers of the pulic, there re few exceptions where insurnce coverge includes tretment not provided or difficult to otin within the NHS, such s dentl cre nd lterntive therpies. Conversely, chronic cre, pre-existing conditions, GP services nd ccident nd emergency cre re ville from the NHS, ut re not covered y PMI. Modelling the decision to purchse privte medicl insurnce Severl fctors impct on the decision to purchse privte medicl insurnce. These include the individul's degree of risk version, premium costs, the perceived mgnitude of potentil loss due to illness reltive to income, nd informtion concerning the likelihood tht n illness will occur. 9,20 Choice nd convenience, s offered y privte helth cre lterntive, re lso enefits sought y PMI suscriers. 2,22 In some cses qulity of cre ville through privte insurnce, reltive to tht ville through n NHS system, my lso e n incentive. The theory of insurnce mrkets plces gret significnce on the concept of risk version. An individul is risk verse if he or she is willing to py to gurntee certinty nd void potentil loss of uncertin size. In helth system where services re pulicly finnced, cre is typiclly provided free t the point of use. Thus no finncil urden exists in ccessing cre. Ptients my, however, seek to void uncertinty s to the witing time for tretment. The nture of demnd for PMI is therefore likely to e significntly different in predominntly pulicly finnced system compred to predominntly privtely finnced system. The potentil finncil loss of ill helth in n NHS system is miniml reltive to system tht hs little or no pulic finncing. Ptients wishing to void the uncertinty tht exists with witing within the NHS must choose etween purchsing PMI or pying for cre out of pocket if nd when ill helth occurs. The decision to purchse PMI must occur prior to the need rising, however, s coverge will not e provided for pre-existing conditions. The perception of NHS qulity cn relte to oth the qulity of clinicl tretment nd the qulity of tretment relted services. Clinicl tretment in privte fcilities is unlikely to exceed tht of the NHS s most physicins who work in the privte sector lso work simultneously in the NHS. It is in the res of choice nd convenience tht the NHS my e perceived to e weker. PMI suscriers my hve the option to choose the fcility t which they receive tretment. They cn lso rrnge to receive tretment in less time thn required in the NHS, t time of their choice, nd in fcility with etter 'hotel' services thn typiclly ville in the NHS. Hll nd Preston put forwrd two possile lterntive explntions s to why individuls purchse privte medicl insurnce. 23 The first is tht there exist individuls who give helth 6

8 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd issues high priority, possily ecuse they re more ferful of ill helth. These individuls my e expected to prioritise incresed pulic helth spending over other pulic spending or the option of lower tx urdens, nd re lso more likely to purchse PMI to ensure ccess to tretment s necessry. The second possiility is tht there my exist shred politicl component to oth the insured decision nd to pulic ttitudes. Individuls who re hostile to the stte my e oth more inclined to meet their own medicl needs privtely nd disinclined to support incresed helth spending. Of the types of chrcteristics impcting on demnd for PMI, personl chrcteristics re the esiest to mesure within survey. Tke, for exmple, ge. An individul in the 35 to 64 yer ge group my consider PMI given his or her incresing likelihood of ill helth. 24 An individul's ge will lso impct on their perceptions of the mgnitude of potentil loss reltive to their income, especilly if pproching retirement nd resultnt fixed income. Another relevnt personl chrcteristic is self-employment. A self-employed individul is likely to desire immedite medicl tretment to void negtive impct on income. 8 By focussing on the PMI purchse decision, net of demnd nd supply effects, we will e estimting wht is known s 'reduced-form' eqution. Reduced-form equtions show how the equilirium vlues of the endogenous vriles chnge s function of the exogenous vriles. 25 This pproch limits us in eing le to show the structure of cuslities, however, nd does not llow us to estimte the impct of specific fctors on either side of the mrket. Attempting to estimte the full structurl model would require identifying the demnd nd supply functions seprtely in two independent models. This would require identifying exogenous vriles tht relte exclusively to either chnges in demnd or supply. The nture of the privte medicl insurnce mrket mkes this tsk very difficult due to the fct tht mny effects re likely to simultneously impct on demnd nd supply. Previous studies in this re hve referred to determinnts of demnd for PMI, ut in fct hve estimted reduced-form models, incorporting fctors tht potentilly impct on oth demnd nd supply. Tke for exmple the effect of income. Income is likely to impct on oth demnd nd supply of PMI. An increse in income my ring out shift in demnd for PMI. Conversely, insurers my im to ppel to suscriers in higher income groups. Consider Figure 2 elow. At n initil point in time (time ), the equilirium quntity of PMI will e q which is the intersection of the demnd function t time (D ) nd the supply function t time (S ). The likely effect of n increse in income for prticulr respondent will e shift outwrds in demnd (D 2 ). Tht is, t ech price, greter demnd for PMI will Structurl models would lso require informtion on price nd cover for ech respondent. 7

9 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Figure 2: The incidence of shifts in PMI demnd nd supply P D 2 S 3 p o2 S S 2 p o D p q q o2 q d q o Q likely exist. If we consider the effects on demnd only, we my expect new equilirium t the volume of q d. However, there is likely to e concurrent increse in supply s insurers seek to gin new usiness from individuls (nd employers on ehlf of their employees) who re in high-income groups. This is represented in the figure s the supply curve S 2.The difficulty is tht t the new equilirium quntity (or prevlence) of PMI, q o, it is difficult to disentngle the contriution of the shift in demnd from the shift in supply. In mthemticl terms, the demnd nd supply functions, D nd S respectively, cn e represented y the equtions: Q d = o - P 2 X 3 W Q s = 0 P 2 Y 3 W where P is the price pid for PMI cover, X nd Y re other fctors tht influence demnd nd supply respectively, nd W is the effect of witing times. Note tht, other things eing equl, the effect of price on the quntity demnded is negtive. Tht is, demnd for PMI is likely to decrese s price increses. Equting Q d nd Q s nd solving for the equilirium quntity will result in n eqution of the form: Q * =c 0 c Xc 2 YdW where 3 3 d = 8

10 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd (for full derivtion of terms see ppendix A). Regression nlysis will not disentngle the demnd-relted component of d ( 3 ) from the supply-relted component of d ( 3 ) within single eqution. Other fctors considered here my hve significnt demnd nd supply effects nd yet show non-significnt overll effect. Consider the effect of deteriortion in helth. Demnd for PMI would likely increse s result, ut insurers would supply less in n ttempt to exclude poor risks. In the figure this is represented y shift to the left in the supply curve. The equilirium quntity supplied in this cse is q o2, which is less thn the quntity demnded if we only consider the demnd effect of poorer helth (q d ). When modelling these effects, nonsignificnt results my occur if demnd nd supply effects cncel ech other out. In ddition to helth sttus, conflicting impcts on demnd nd supply of PMI could e fctor with other individul chrcteristics such s ge nd employment sttus. Insurers djust premiums sed on ge, nd the vilility of PMI cover t given price will e significntly curtiled the older the insuree. With respect to employment sttus, insurnce compnies my void risks if they feel the insuree my e unle to py the premium. Evidence from empiricl studies Previous empiricl studies hve exmined the ssocitions etween personl chrcteristics nd prevlence of PMI. Also considered re indices of NHS qulity, most often witing times, nd ttitudes to the pulic nd privte sector. Other nlyses of PMI demnd hve exmined the importnce plced on choice nd convenience y the pulic, the level of worry over helth, ttitudes towrds risk nd towrds the pulic nd privte sectors. Tle provides summry of previous studies in this re. Age, income nd eduction hve repetedly een found to e positively ssocited with the demnd for PMI. 5,22,26,27,28 Propper (989) lso found significnt ssocition etween employment sttus nd hving PMI. Those in work nd with spouse in work were significntly more likely to hve PMI. Other personl chrcteristics such s socio-economic sttus, self-employment nd home ownership, were not found to e sttisticlly significnt in this study though Besley et l (993) nd Emerson et l (200) found the ltter to e significntly ssocited with PMI coverge nd Bosnquet nd Pollrd (997) reported tht those in socil clsses A nd B were more likely to e covered y PMI. Emerson et l (200) oserved in their study tht self-employed individuls were less likely to hold PMI. Bosnquet nd Pollrd (997) found tht men were more likely to e covered y PMI thn women nd Conservtive prty supporters were more likely to e covered thn Lour supporters. The other studies to test these effects, Emerson et l (200) nd Besley et l (999) respectively, rrived t similr results. Besley et l (993) nd Emerson et l (200) found significnt negtive ssocition etween the numer of children in household nd prevlence of PMI. Tht is, respondents from households where there were reltively high numer of children were less likely to hold PMI coverge. Some focus hs een plced on helth sttus nd it's impct on demnd for PMI. Propper (989 nd 993) included indices of helth sttus in her nlysis, ut this ws not found to chieve sttisticl significnce. The indices used included hving reported chronic illness, 9

11 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd hving hd n inptient sty in the pst yer, hving hd n outptient sty in the pst yer, nd hving hd GP visit in the previous 2 weeks. The lck of n ssocition etween helth sttus nd PMI coverge my reflect the fct tht future expected helth is greter determinnt of PMI purchse thn current helth, though empiricl evidence lso suggests tht eing smoker does not increse or decrese the likelihood of hving PMI coverge. Propper (993) did find tht poor helth of spouse ws ssocited with hving PMI coverge. Vrious indices hve een employed to represent spects of NHS qulity reltive to privte tretment. NHS qulity my e reflected in witing times. Besley et l (999) nd Propper (999) did not find positive ssocition etween the numer of individuls in the respondent's region witing for inptient cre nd the likelihood of hving PMI coverge. Besley et l (999) did oserve tht in regions where those witing over 2 months for inptient cre ws reltively high, there were significntly more PMI suscriers. In 99, questionnire survey of privte hospitl ptients ws conducted in the Wessex regionl helth uthority to determine their resons for using privte helth cre services. 29 NHS witing lists re the most common reson given. Interestingly, however, the respondents were unwre of how long the witing list hd een. And while the mjority of respondents hd mde decision out using privte helth cre efore consulting with their GP, they tended to e influenced y their GPs dvice on the choice of consultnt nd choice of hospitl. Clnn et l. (993) report similr finding on the significnce of NHS GP dvice. Witing times do not necessrily reflect NHS qulity with regrds to efficiency. Clnn et l (993) oserved tht regionl sed witing lists were not relted to the numer of ptients treted cross regions. This is not to sy tht the effect of witing is not importnt, ut rther tht the impct of witing should e considered in ddition to proxy for NHS qulity, if such mesure cn e derived. Qulittive dt from Clnn et l (993) suggests tht respondents do mke this distinction. They did not identify qulity distinctions etween privte nd NHS services, ut did express concern over witing times. Propper et l (200) considered the numer of privte hospitls (deflted y popultion size) s n index of privte sector cpcity in recent nlysis of the demnd for PMI nd found them to e sttisticlly significnt. 30 The use of this index ssumes comprle numer of eds in ech fcility. This my not e the cse, however, s privte hospitl cpcities vry considerly in size. Bosnquet nd Pollrd (997) found tht respondents commonly identified choice nd convenience s resons for hving PMI. Thirty-seven %identified the swiftness of receiving tretment s n dvntge of PMI, 26% mentioned the ility to choose when to e treted, nd 23% liked the ese with which consulttions my e rrnged with PMI coverge. 0

12 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Tle - Results of Previous Anlyses of the Demnd for Privte Medicl Insurnce '' denotes sttisticlly significnt (p<0.05) positive ssocition; '-' denotes sttisticlly significnt (p<0.05) negtive ssocition; 'ns' denotes vrile not sttisticlly significnt Predictors Propper (989) Propper (993) Besley et l (999) Propper et l (999) Emerson et l (200) Regionl vrile ns not reported not reported Age (ii) (iv) Sex: Mle Socio-economic sttus ns Hed of household in work Spouse in work Self-employed ns ns - Overtime - (re: spouse) Helth sttus ns - (re: spouse) Smoking ns Recent use of helth services ns Ns Income Eduction Lives lone Ns (i) Owner-occupied home ns Worry over helth Ns Attitude to risk Attitude to privte sector Ns Work in the pulic sector - Currently witing for inptient cre ns ns Currently witing over 2 months for inptient cre Other indices of NHS qulity ns (iii) Numer of dults - Numer of children - - Politicl eliefs: Conservtive Employed s mngeril/technicl stff Household svings i. 'Lives lone' ws not considered, ut income vrile is sed on household income; lso the numer of dults in household is considered. ii. Also, ge cohort is significnt t p<0.05 nd positively relted to demnd for PMI. ie. Those in prticulr ge group t lter point in time re more likely to purchse PMIthn those of the sme ge group t n erlier point in time. iii. Vriles found to e significnt in seprte models include the interction of NHS nd dummy vrile reflecting the post 99 reform period, the interction of numer of prt time consultnts nd the post- 99 dummy vrile, nd the interction of the numer of privte hospitls nd the post-99 dummy vrile. iv. Prtner's ge lso sttisticlly significnt.

13 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Propper (993) included indices of the level of worry over helth nd ttitude to risk in her nlysis of demnd for PMI nd found the ltter to e significntly ssocited with demnd for PMI. Respondents who sid they would void pying for privte cre t the point of demnd were more likely to hve PMI coverge. Also included in this study ws n index of ttitude to the privte sector, found not to e ssocited with PMI coverge. Besley et l (999) included n index of ttitude to the pulic sector in their nlysis nd found negtive ssocition etween this vrile nd hving PMI coverge. Some consistent findings re pprent, though some inconsistencies exist. Though the studies vry in their methodology, there is overwhelming evidence tht high socio-economic sttus is ssocited with incresed demnd for PMI. Amongst personl chrcteristics, incresed ge (especilly eing etween ge 40 nd 60), high income, high eductionl chievement nd non-mnul employment re ssocited with incresed demnd for PMI. Also, the importnce of disposle income is evident from the significnce of living with prtner, living without children nd living in owner-occupied housing. As disposle income increses, the rtio price to income decreses. This llows for greter quntity to e demnded t ny given price. Results exmining the impct of NHS witing times re inconsistent, s re other indices of NHS qulity. The impct of politicl preference is determined to e significnt in some studies, ut not significnt in others. And link etween eing self-employed nd hving PMI is not unnimous. Developing hypotheses nd reserch questions Bsed on theory nd ville empiricl evidence, the PMI purchse decision would pper to e sed on severl multifceted determinnts. One significnt fctor is n individul's economic mens. Unless their disposle income llows such purchse, individuls nd fmilies re likely to forego PMI s compred to more fundmentl needs such s food nd shelter. Employment sed PMI lso reflects economic mens s it is most often high pid workers who re given PMI y their employers. The importnce of disposle income cn e judged y ssessing the effects of proxies such s individul income, type of employment, nd whether respondents live with spouse or prtner, on PMI coverge. Premium costs will lso impct on PMI prevlence. The increse in premiums in the individul PMI mrket, nd the concurrent decline in the prevlence of individul PMI coverge, reflects this fct. A significnt ssocition etween ge nd PMI demnd my reflect n individul's perception of their potentil exposure to illness. In prticulr, n individul pproching old ge, who hs enjoyed good helth nd for whom the cost of PMI coverge is mngele, is likely to emphsise the positive spect of hving PMI coverge (incresing helth cre needs, choice nd convenience) in weighing up the decision of whether or not to purchse privte medicl insurnce. These fctors will hve to e weighed ginst the reltively high premiums tht re required to otin cover. Due to the incresing prevlence of employer pid PMI in certin employment sectors, it is likely tht employment relted fctors such s income nd type of jo will hve diminishing impct on individul PMI demnd. This is likely to occur, s significnt numer of 2

14 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd individuls who would hve considered PMI coverge re incresingly likely to receive it s enefit from their employer. Not much is known out the criteri tht impct on the purchse decision of employers, though the competitiveness of enefit pckges in certin employment sectors, nd the ility to reduce potentil lost productivity due to ill helth of employees my e driving the growth in employer pid PMI. As previously noted, risk version is linked to perceptions of the risk of dely in ccessing medicl tretment in the NHS. Perceptions of dely, in turn, re likely sed on medi reports nd GP dvice on witing times. Mesuring risk version is difficult, however. At est, surveys re le to mesure fctors tht contriute to uncertinty nd the potentil for loss. We hve used NHS witing times s proxy to represent the degree of uncertinty tht ptients my fce. By including these dt, we ttempted to mesure potentilly key influencing fctor on the perception of risk with regrds to medicl cre. Witing times my lso impct of the supply of PMI. Insurers re likely to trget geogrphicl res where they know witing times re reltively high. Uncertinty is only one spect of NHS performnce tht my influence demnd for PMI, however. Qulity, in terms of helth outcomes nd fcilities, nd ptient experiences re other importnt fctors. The impct of witing times my not hve n immedite effect on demnd, nd one would expect gp in time during which version to potentil dely in seeking medicl services incresed to the point where the decision to purchse PMI ws mde. We hypothesise tht the ssocition etween witing times nd demnd for PMI is strongest when this delyed effect is ccounted for. Other supply- side fctors my lso e relevnt. While the survey dt does not indicte whether or not respondents re wre of the ccessile privte fcilities in their re, dt on their prevlence cn e used to indicte the likely impct they hve in the decision y individuls to purchse PMI coverge. The reltive significnce of individul wreness of ccessile fcilities versus their ctul prevlence my e minor if the individul is relint on their GP for dvice with regrds to the merits of the privte versus the pulic sector. The theory nd empiricl evidence on the PMI purchse decision suggests reserch questions relting to the impct of personl chrcteristics such s income, employment sttus, ge nd ttitude to the privte sector, long with premium costs, risk version, NHS performnce nd the prevlence of privte fcilities. The ville dt from the BHPS re suitle for exmining some of these questions ut not others. Where relevnt dt exist we hve specified hypotheses tht will e tested. These re: ) Hving individully finnced PMI coverge is primrily dependent on hving disposle income tht llows one to cover premium costs. 2) The prevlence of individully finnced PMI coverge is higher mongst individuls in older ge groups ecuse incresing ge is likely to e relted to incresing version to risk. 3) Individuls who identify themselves s politiclly Conservtive re more likely to suscrie to PMI. This ideology is in line with positive ttitude towrds the privte sector. 4) The prevlence of employer finnced PMI is likely to e relted to employment fctors tht indicte mngeril or service sed employment. 5) NHS witing times re one spect of perceived NHS qulity tht my impct on the purchse decision. The effect of witing times is more likely to e oserved if one llows for 3

15 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd time lg etween witing times informtion reching the pulic nd the ssocited demnd for PMI eing oserved. 6) The prevlence of privte eds nd physicins on mximum prt-time or prt-time contrcts impcts upon the prevlence of PMI. 7) The removl of the tx susidy to PMI suscriers over the ge of 60 hs hd significnt impct on the prevlence of PMI mongst this ge group. 8) Individul PMI suscriers who gve up their PMI cover susequent to the removl of the tx susidy were likely to e pying higher premium nd thus more likely to e effected y the loss of the susidy. We re unle to drw direct conclusions from the dt on other spects of the reserch questions, such s the effect of risk version nd ttitudes towrds the pulic nd privte sectors, due to the fct tht the ville dt re not menle to exmining these specific topics. But in some cses, proxy dt, such s ge s proxy of risk version, my e used to gin some insight into the nture of their reltionship to the PMI purchse decision. Methods The British Household Pnel Survey (BHPS) is n nnul survey tht egn in 99. It follows the sme representtive smple of individuls over time. The BHPS egn including questions relting to the prevlence of privte medicl insurnce in its sixth wve, in 996. The dt from the British Household Pnel Survey is suitle for n nlysis of the decision to purchse privte medicl insurnce s it incorportes questions relting to personl chrcteristics nd situtionl vriles collected for individuls within households over time. The British Household Pnel Survey (BHPS) is eing crried out y the Institute for Socil nd Economic Reserch t the University of Essex. The initil smple for Wve One of the BHPS consisted of 8,67 issued ddresses in Britin, drwn from the Postcode Address File. The initil selection of households for inclusion in the pnel survey ws mde using twostge clustered proility design nd systemtic smpling. 3 Interviews were ttempted t ll privte households found t these ddresses. All individuls enumerted in respondent households ecme prt of the longitudinl smple. The smple for the susequent wves consists of ll individuls over ge 5 in ll households contining t lest one memer who ws resident in household interviewed t Wve One. Further informtion on the smpling nd survey design is ville from the BHPS Online documenttion. 29 Three questions in the BHPS descrie privte medicl insurnce coverge. Respondents re sked if they re covered y privte medicl insurnce, how the insurnce is pid for (if they re covered), nd wht is the cost to the respondent of the medicl insurnce. We lso identified severl possile determinnts of medicl insurnce prevlence from the BHPS. These include ge, eductionl chievement, income, re of residence, whether the respondent is in pid employment, politicl prty supported, sex, self-reported helth sttus, whether the respondent smokes, whether the respondent lives lone or with prtner nd whether or not there re children living in the respondent's household. There re limittions in the use of the BHPS dtset, however. While the survey exceeds other lrge surveys in the numer of questions relting to PMI coverge, it ws not designed for this purpose specificlly nd thus omits some relevnt informtion. In prticulr, dt on premium costs re only ville for individul suscriers. Idelly, premium cost dt would 4

16 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd lso e ville for individuls with compny pln, long with the premium they would e likely to py if they hd chosen to insure individully. Also useful would e dt on the extent of PMI cover. Ech PMI pln will offer different levels of nd options for tretment. Unfortuntely, this informtion is lso not ville from the BHPS questionnire. And limited dt on out-of-pocket pyments exists. Less thn 4% of BHPS respondents without PMI who hd privte hospitl inptient sty or visited privte consultnt or specilist pid for these services out-of-pocket. This rte is lower thn other estimtes of the prevlence of out-of-pocket pyments. 32 Compring PMI suscriers with out-of-pocket helth purchsers would e n interesting exercise, ut giving the pprent low prevlence of the ltter group in the BHPS dt, the results my e misleding. Of the vriles included in our nlyses, perhps the most prolemtic is income. Survey questions relting to income re often met with reserve, due to concerns out confidentility nd how the informtion will e used. 33 Also, income dt my misrepresent finncil welfre s it does not tke into ccount fmily size nd geogrphic differences in the cost of living, 34 nd typiclly does not include investment income. 35 These prolems re not specific to the BHPS, however. The Fmily Expenditure Survey used y Propper et l (2000) nd the British Socil Attitude Survey used y Besley et l (998) hve similr deficiencies. A proxy of spending power would e disposle income. Dt on witing lists nd witing times, ggregted y helth uthorities, ws linked to individul responses ccording to their plce of residence. The indices employed were the percentge of ptients who wited over 6 months for n inptient sty nd the percentge of ptients who wited over 3 weeks for n outptient ppointment. While it is true tht witing lists nd witing times would not necessrily e consistent within helth uthority, nd thus would not influence individuls within helth uthority identiclly, this seemed the most pproprite wy to tke ccount of the extent to which respondents were influenced y the level of wit encountered in the NHS. Sensitivity nlysis incorporting dt on witing times ggregted t the regionl level ws lso conducted to determine the extent to which the unit of ggregtion of witing times dt influenced the results. Finlly, ecuse vritions exist in how witing lists re determined in Englnd, Scotlnd nd Wles, we restricted our nlysis to residents of Englnd. We otined dt on the supply of privte eds, t the regionl level, in Within much of Englnd, the distriution of privte fcilities is such tht the popultion will not hve ccess to more thn one fcility. This is not the cse in London nd the South Est, however, where the concentrtion of fcilities is reltively high. For this reson, we used the wider regionl level to ssign ccess to privte eds to respondents. The numer of privte cute medicl nd surgicl eds per 00,000 popultion ws clculted for ech region nd linked to individul respondents. 37 Disposle income reflects the ctul ccess to finncil mens of n individul or household tht could e spent on insurnce premiums. Also, it cn incorporte sources of income outside of slries nd wges. It does not, however, negte concerns for confidentility. Inptient witing times dt is popultion sed nd includes ordinry dmissions nd dy cse witing lists for every Helth Authority (HA) in Englnd verged over the clendr yer. Outptient witing times dt is lso popultion sed nd includes detils for first outptient ppointments for ech Helth Authority (HA) in Englnd verged over the clendr yer. 5

17 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Additionlly, we sought to exmine the effect of the regionl distriution of physicins working in the privte sector. To pproximte this dt we included the numer of NHS physicins working under mximum prt-time nd prt-time contrcts per 00,000 popultion in ech of the eight regions in Englnd s of Septemer This dt my not ccurtely reflect the numer of physicins working privtely, however, s mny physicins my e working prt-time in the NHS to llow for time to utilise in wys other thn working privtely. We lso included in the nlyses the effect of the distriution of surgeons working under mximum prt-time nd prt-time contrcts per 00,000 popultion s of Septemer The distriution of surgeons cross contrct type vries considerly from tht of consultnt physicins overll, with greter proportion of them working under mximum prt-time contrcts. Bsed on Deprtment of Helth dt tken in Septemer 2000, 26.7% of consultnt physicins were working under mximum prt-time contrcts, while within the surgicl group the corresponding percentge ws 43.9%. 38 The BHPS dt differentites etween PMI holders ccording to how premiums re finnced. It is possile to differentite etween those individuls who purchse PMI individully, nd those who receive PMI s n employment enefit for which they do not py t ll. Some individuls report eing covered under policy in fmily memer's nme. It is not lwys cler from the dt, however, if the person under whose nme they receive coverge hs pid the insurnce premiums individully or through n employment-sed pln. As such, respondents covered y fmily memer's coverge re excluded from our nlysis. Some individuls py prt of the premium for employment-sed group coverge. Some of these individuls would e in position to choose whether or not to suscrie, given tht the premiums re coming out of their ernings. Thus, they re expressing demnd for PMI. We cn lso ssume, however, tht the premiums they py s prt of group pln re less thn tht which they would hve encountered hd they purchsed individully. So while some my hve purchsed PMI regrdless, some my hve chosen not to purchse PMI if they hd een fced with higher premium. Due to the vriility in the circumstnces likely within this sugroup, we chose to exclude them from the nlyses. The dt re first modelled ssuming multinomil distriution for the BHPS dt (model ). By so doing, the purchse decision of the individul suscrier nd the employee-pid group suscrier cn e nlysed s seprte groups. Both groups re compred to non-pmi holders. Dt for 996 is not included due to the unvilility of outptient witing times, t the helth uthority level, for this yer. In the cse tht dt for prticulr respondent ws not ville for one of the yers considered, the model llowed for inclusion of dt for those yers tht were ville. In the multinomil logit model, we re interested in estimting three sets of coefficients β, β 2, β 3. If we set one set, e.g. β 3 to zero, this llows the remining coefficients β nd β 2 to e interpreted s the chnge reltive to the y = 3 group. Setting β 3 = 0, the proility outcome equtions re: 40 Prt-time is used here to refer to contrcts. Consultnts on mximum prt-time contrcts receive 0/ of the full NHS slry nd re not suject to limit on their privte ernings. Herein, we refer to privte physicins nd privte surgeons to refer to physicins nd surgeons on mximum prt-time nd prt-time contrcts. 6

18 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Pr( y = ) = e e Xβ () Xβ () e Xβ (2) Pr( y = 2) = e e Xβ (2) Xβ () e Xβ (2) Pr( y = 3) = e Xβ () Xβ (2) e The reltive proility of y =2tothesectegoryy =3is: Pr( y Pr( y = = 2) 3) = e Xβ (2) This rtio is the reltive risk. If we then ssume tht X nd β k (2) re vectors equl to (x, x 2,..., x k ) nd (β (2), β 2 (2),..., β k (2) )', respectively, then the rtio of the reltive risk for one-unit chnge in x i is then: 40 e β (2) x e β... β (2) x (2) i... β ( x )... β i (2) i i x... β (2) k xk (2) k xk = e β (2) i Therefore, the exponentited vlue of coefficient is the reltive 'risk' rtio, or reltive likelihood, for one-unit chnge in the corresponding vrile, where 'risk' is mesured reltive to the se ctegory. The sttisticl pckge STATA estimtes the mrginl significnce level of ech term in the model (tht is, the significnce level of ech effect over nd ove tht oserved from the other effects in the model). 39 The reltive mgnitudes of the most significnt effects re represented grphiclly. A hypotheticl comintion of fctors ws chosen nd the predicted proility of n individul with these chrcteristics hving individully purchsed PMI ws clculted. Ech fctor ws then ltered in turn to illustrte the reltive effects of ech. The pnel nture of the dt llows for considertion of lgged effects. Becuse the effect of NHS witing times my not hve n immedite impct on the insurnce purchse decision, models were considered in which NHS witing times dt from 997 nd 998 were included in cross-sectionl multinomil logit nlysis of the 998 nd 999 BHPS dt (model 2). In ll the models we deemed p-vlues elow 0.05 to indicte sttisticl significnt ssocitions. 7

19 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Results The 996 smple of the British Household Pnel Survey includes 8,25 individuls who reside in Englnd. In the yers 997, 998 nd 999 the smple lost 7.6%, 8.0% nd 8.0% respondents respectively. The overll smple incresed, however, to size of 9,97 individuls in 999. This is the result of dditionl individuls eing included in the smple s individuls come to shre household with n originl smple memer. The nlysis includes respondents with dt for those yers tht they were prt of the overll smple. The 999 smple includes of 435 individuls who hve individully purchsed PMI (4.7% of smple), 0 who re prt of compny PMI pln in which the premium is deducted from their slry (.2%), 49 who receive PMI s enefit from their employer (5.3%) nd 466 who re covered y pln held y fmily memer (5.%). Of those covered y fmily memer, 66.0% hd nother respondent within their household who hd PMI in their own nme. Of these, 37.7% pid for coverge directly, 3.8% hd the premiums deducted from their slry, nd 48.% hd the premiums fully pid y their employer. Distriutions of the explntory vriles pper in Appendix B, tles, 2 nd 3. The verge ge (40.6 yers) of those receiving PMI s n employer provided enefit ws lower thn in ny of the other sugroups. They lso hd higher incomes. The verge monthly income for n individul receiving PMI s enefit from their employer ws 2,432, while individul suscriers erned on verge,66 per month nd respondents without PMI erned 932 on verge. A similr proportion of those receiving PMI s enefit, nd those who hd compny-sed PMI for which they pid ll or prt of the premium were women (29.9% nd 30.9% respectively). Approximtely 55% of those without PMI were women, nd in the sugroup of individuls who were covered y fmily memer, 3 out of 4 were women. These comprisons re shown in Tle 2. As descried ove, the first model compred those with individully purchsed PMI nd those with employer pid PMI with those without PMI cover. Dt from the three-yer period ws used in this nlysis. In the comprison of individul suscriers with nonsuscriers, the results of the multivrite nlysis deemed sttisticlly significnt determinnts of PMI prevlence to e eduction, income, sex, ge, eing in good helth (self reported), politicl preference, the supply of privte surgeons, nd living in household with children. Tle 3 reports these results. Positive coefficients indicte positive reltionship with PMI prevlence. With respect to eduction, those with eduction ove O-level ttinment were more likely to hve PMI reltive to those without this level of eduction. Income nd ge illustrte effects tht chnge t different points in their distriution. This is reflected in the significnce of oth liner nd squred terms for these vriles. Conservtive voters nd men re more likely thn other voters nd women respectively, to hve PMI. Also, those living in household with one or more children re less likely to hve PMI. Finlly, there exists n incresed prevlence of PMI in regions where the numer of surgeons on prttime NHS contrcts, is reltively high. This is ssumed to reflect n ssocition etween the supply of surgeons working privtely nd the prevlence of individully purchsed PMI. The effects of eing in pid work, eing in verge helth (reltive to poor helth) nd eing non-smoker ll show trend towrds greter likelihood of hving PMI. This is reflected in their p-vlues pproching sttisticl significnce. 8

20 The Determinnts of Privte Medicl Insurnce Prevlence in Englnd Tle 2 - Comprison of demogrphic chrcteristics y type of PMI cover (999 dt) Individul Compny pln - employee finnced (n=0) Compny pln - employer finnced (n=49) Covered y fmily memer No PMI (n=435) (n=466) (n=7,080) Age (men) 52.9 yers 43. yers 40.6 yers 4.9 yers 48.5 yers Monthly Income (men),66,768 2, % femle % with Postsecondry eduction

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